In the wake of misinformation-fuelled protests in Australia and other countries, the latest edition of The Health Wrap brings a timely examination of the many drivers of misinformation and disinformation, flags concerns about a new coronavirus variant, and reports on the moral justification for patient-centred care.
From the United States, there is news of a spike in drug overdose deaths and a billion-dollar settlement of lawsuits over the opioid epidemic. And from Sydney comes a new publication describing the Redfern Aboriginal Medical Service’s longstanding contributions to drug and alcohol treatment.
And, at last, a good news story on COVID vaccination – from the 1,500-strong population of Tokelau, one of the world’s most inaccessible atolls, some 3,500 kilometres north of Auckland. (And don’t miss the video).
Lesley Russell writes:
As NSW struggles to bring the current outbreak of the Delta strain of coronavirus under control, there are fears of an emerging new and possibly more lethal variant, Lambda.
Lambda apparently emerged in Peru – it was initially reported in Lima in August 2020, and by April 2021 it accounted for 97 percent of all cases in Peru. But it didn’t stay in Peru and according to a recent World Health Organization (WHO) report, it is now in 29 countries.
At least one case has been found in Australia, in someone in hotel quarantine.
Scientists are worried about Lambda’s unusual combination of mutations, which could make it more transmissible.
There are several mutations on the spike protein, the projections on the outside of the virus that help it latch on to cells and invade them. Apart from making it easier for this variant to invade cells, these mutations also make it harder for antibodies to latch onto the virus and neutralise it.
Lambda also has other mutations, including one similar to a mutation that is thought to make Delta more infectious. In Australia CSIRO scientists are investigating the importance of these structural changes.
There is as yet little published research to indicate the real threats Lambda poses and whether it will replace Delta as the international threat.
The WHO last month classified Lambda as a global “variant of interest” – a step below variant of concern. Lambda has appeared in the United States (the full extent is unknown because the US does so little genomic sequencing) but the Centers for Disease Control and Prevention (CDC) has not listed it as a variant of interest, concern or high consequence.
According to Public Health England’s July 8 risk assessment, there is no evidence of a country where Lambda has outcompeted Delta.
There are a few studies that indicate current vaccines should be able to protect against this new variant.
One US study available as a preprint looked at the effect of the Pfizer and Moderna vaccines against the Lambda variant and found a two-to-threefold reduction in vaccine-elicited antibodies compared with the original virus. This is not considered a massive loss of neutralising antibodies and the researchers conclude that these mRNA vaccines will probably remain protective against Lambda.
Researchers from the University of Chile investigated the effect of the Sinovac vaccine. They also found a threefold reduction in neutralising antibodies compared to the original variant.
For more reading on this topic:
ABC News: The Lambda coronavirus variant has arrived in Australia. Here’s what we know so far
ABC News: The Lambda variant: Is it more infectious and can it escape vaccines?
Countering the misinformation epidemic
The enormous amount of misinformation (some deliberate, some arising out of lack of knowledge or fear) around the coronavirus pandemic has sometimes been seen as a pandemic in its own right.
We saw the social consequences of the spread of disinformation and misinformation this weekend with mass protests in Sydney, Melbourne and elsewhere. Sadly we might see the health consequences soon if these turn out to be super-spreader events.
Recently this concern has been tackled head-on in the United States by both President Joe Biden and the US Surgeon General Dr Vivek Murthy.
Biden, in response to a question about platforms such as Facebook that amplify scientifically false anti-vaccines claims that deter people from getting vaccinated said: “They’re killing people”.
White House press secretary Jen Psaki put the President’s comments in a more low-key perspective:
“We’re dealing with a life-or-death issue here and so everybody has a role to play in making sure there’s accurate information. They’re a private sector company. They’re going to make decisions about additional steps they can take. It’s clear there are more that can be taken.”
The Biden Administration has announced that it is taking more aggressive action and is flagging problematic posts for Facebook that spread misinformation.
“We are regularly making sure social media platforms are aware of the latest narratives dangerous to public health that we and many other Americans are seeing across all of social and traditional media,” Psaki said. “We work to engage with them to better understand the enforcement of social media platform policy.”
Democrats led by Senator Amy Klobuchar have introduced a bill that would punish social media companies if their algorithms promote health misinformation (as defined by the Department of Health and Human Services) during a public health crisis.
At the same time the US Surgeon General released an Advisory to warn the American public about the urgent threat of health misinformation. (A Surgeon General’s Advisory is a public statement that calls the American people’s attention to a public health issue and provides recommendations for how that issue should be addressed. Advisories are reserved for significant public health challenges that need the American people’s immediate awareness.)
The Advisory outlines actions – simple measures of what can be done, just three to five in each category – by the following groups in society:
- Individuals, families and communities
- Educators and educational institutions
- Health professionals and health organisations
- Journalists and media organisations
- Technology platforms
- Researchers and research institutions
- Funders and foundations.
Perhaps the most important point the Advisory makes is that:
Misinformation thrives in the absence of easily accessible, credible information.
When people look for information online and see limited or contradictory search results, they may be left confused or misinformed.”
A study by the Center for Countering Digital Hate in the United States looked at content posted or shared to Facebook, Instagram and Twitter in February and March and found that just twelve anti-vaxxers (dubbed the Disinformation Dozen) were responsible for 65 percent of anti-vaccine content circulating on social media platforms.
It’s shocking that some of worst spreaders of misinformation are doctors. See for example this story from The New York Times about one of the so-called Disinformation Dozen.
And read more about this study in Jennifer Doggett’s report for Croakey in April.
A concerted national effort is obviously needed in Australia to counter efforts such as those from Clive Palmer (how much money has he spent on this national effort?), Craig Kelly and Alan Jones (with plenty of free air time) and others.
A report released in May by Reset Australia found that the rise in vaccine hesitancy here has coincided with a 280 percent increase in anti-vaxx group membership on Facebook.
An analysis of 13 Australia-based public groups on the social media platform, conducted from January 2020 to March 2021, found they were responsible for generating more than 2.66 million interactions around the safety and efficacy of vaccines, the promotion of drugs ivermectin and hydroxychloroquine, and mandatory vaccination programs.
These findings were described as just the ‘tip of the iceberg’, with the real dangers being the algorithms of Facebook, YouTube and Twitter that allow misinformation to spread.
There is a Myth Busting site on the Australian Government’s COVID-19 website but you really have to go looking for it, and its language (English only) is not particularly user-friendly.
I was surprised to discover that the Department of Health has collaborated to the Australian Academy of Science to produce a “Science of Immunisation” booklet (who knew?). There’s not enough information for people like me, and probably too much for many people, it’s at a level that might be useful for high school science students. I can’t see it persuading anyone who is vaccine hesitant to get vaccinated.
Aside from the obvious gaps here – gaps that could be filled with the $40 million Morrison says is available for communications efforts – there is also the fact that coronavirus and vaccine misinformation is spreading in many different languages.
Australia’s multicultural communities have long been calling for tailored communication information delivered through a range of accessible mechanisms.
Further reading on this topic from the Croakey archives here:
Bill Bowtell: Billionaire’s vaccine misinformation campaign a threat to public health.
Matthew Nguyen: Is misinformation the public health challenge of the 21st century?
And this from 2015 – sadly highlighting we were warned and still have done nothing:
Adam Dunn and Julie Leask: How to address the persistence of misinformation about vaccines online?
It is worth watching this interview mentioned below, including discussion of the “weaponised campaign of health information” via Russia.
On patient-centredness
The concept of patient-centredness was first put forward in the 1960s, and its early focus was on the relationship between a patient and their doctor. Since then, the construct of patient-centred care has extended beyond the level of the clinical encounter to the practice setting and the broader healthcare system; it is an explicit focus of the patient-centred medical home.
A paper from Australian researchers, just published in BMJ Quality and Safety (sadly the full article is not publicly available), looks at how Australian patient advocates and GPs have come to think of patient-centred care and how well they thought it was supported by the healthcare system.
While both groups saw the concept as being fundamental to quality care, they thought about patient centredness in diverse, personal and sometimes inconsistent ways.
The GPs viewed it mainly in terms of relationships, and its centrality to the core function of general practice.
The patient advocates spoke of its relevance to their own experience as patients and to their role in promoting the needs of those for who may not otherwise have a voice. They were more attuned to the factors influencing its delivery.
The authors highlight that these diverse approaches can hinder strategies to implement and sustain patient-centred care improvements.
In an editorial commenting on this paper, Professor Grant Russell from Monash University explores some of the history of patient-centred care and makes the point that there is nothing fundamentally wrong with a broadening of the concept from a focus on the clinical encounter to one embracing models of care and the way entire health systems are organised.
But he asks: have we forgotten the moral justification for patient-centred care?
This moral dimension (sometimes referred to as humanistic care) is about the sharing of power and control, and is a justification in itself, regardless of any measurable relationship with health outcomes.
Russell suggests that this “may be a path to us having a truly reformed clinical method – closer to the needs of the patient and the clinician, and something that can … act as an antidote to organised medicine’s insensitivity to suffering and all too frequent abuse of power.”
I like that! And I also like this quote that I found while exploring this topic:
Humanistic health professionals care about their patients as much as they care for them.”
Clearly, one way to proceed is to ask patients what they need – and then act on it. A paper from Germany, published in BMJ Open in June, looked patients’ perspectives on patient centred care.
They found patients mostly focused on three major themes:
(1) Time appropriate access to care
(2) Competence, empathy and being taken seriously by healthcare professionals
(3) Health care professionals’ individual consideration of each patient’s situation (for example, wishes and needs).
Minor themes were:
(1) Taking a holistic perspective of the patient
(2) Patient-centred communication
(3) Integration of multidisciplinary treatment elements
(4) Transparency regarding waiting time
(5) Reduction of unequal access to care.
Isn’t it fascinating how time is such an important factor here?
I’m sure these issues would also be important for Australians, although I suspect that the ordering would vary considerably, depending on people’s cultural and ethnic backgrounds.
Dreadful toll of drug overdose deaths in the United States
As COVID-19 raged across America last year so did the country’s drug epidemic.
Drug overdose deaths rose nearly 30 percent in 2020 to a record 93,000, according to preliminary statistics released by the Centers for Disease Control and Prevention.
Opioids – mostly synthetic opioids – were involved in three-quarters of these deaths, killing 69,710 people.
This is not just the largest single-year increase ever recorded but encompasses several other grim records: the most drug overdose deaths in a year; the most deaths from opioid overdoses; the most overdose deaths from stimulants like methamphetamine; the most deaths from synthetic opioids known as fentanyls.
These drug deaths were experienced disproportionately among young Americans. An analysis by The New York Times found that the 93,000 deaths cost about 3.5 million years of life; by comparison, coronavirus deaths in 2020 were responsible for about 5.5 million years of life.
The pandemic itself undoubtedly contributed to the surge in overdose deaths, with disruption to outreach and treatment facilities and increased social isolation. But drug deaths were rising even before COVID-19 arrived.
President Trump talked a lot about the opioid crisis but the small efforts his Administration made in this area were undermined by attempts to dismantle Obamacare and Medicaid. The Biden Administration made the drug problem a top priority even before it came into office, but now it faces a very difficult task.
Experts have put forward a number of ways to improve the current situation. Key among these is fully integrating addiction treatment and care into the American health care system.
At the same time as the drug death statistics were made public it was announced that the three biggest opioid distributors and drugmaker Johnson & Johnson have reached a $26 billion settlement to resolve thousands of lawsuits over the opioid epidemic.
The companies have denied wrongdoing and reached this agreement (yet to be formally accepted by the complainants) in an effort to resolve more than 3,000 lawsuits brought by states, cities, counties and other jurisdictions. These were consolidated into one of the largest and most complex civil litigation battles in US legal history. A settlement has not yet been reached between the companies and Native American tribes.
Under the settlement, Johnson & Johnson would be barred from manufacturing, marketing and selling opioids. The company voluntarily halted sales of pain pills last year.
The deal would also require the distributors to establish and fund a “clearinghouse” that shows where every opioid dose is headed, an accountability mechanism that would alert regulators of suspicious orders.
The settlement money would be spent on treatment, prevention, education and other costs of the epidemic. Private attorneys will recoup nearly $2 billion of the funds.
This is not the first such settlement – and it will not be the last.
In 2019, a judge in Oklahoma ordered Johnson & Johnson to pay $572 million after ruling the company was partially responsible for the state’s opioid epidemic.
Last month, Johnson & Johnson settled a similar case in New York for $230 million
The billionaire Sackler family offered $4.28 billion of their personal fortune to help settle lawsuits related to Oxycontin, made by their company, Purdue Pharma, as part of a bankruptcy proposal (yet to be accepted).
What’s happening in Australia? As is so often the case, the data are slow to emerge, so it’s hard to know the impact of the pandemic.
The Penington Institute’s annual overdose report released last August showed that in 2018, more than 2,000 people died from drug overdoses in Australia — about five each day. The largest number of overdose deaths (more than 1,000) involved opioids (for example, heroin, morphine, oxycodone, fentanyl), followed by benzodiazepines (for example, Valium).
Opioid-related deaths in Australia have been on an upward trend since 2006. However, the most recent data from the Australian Institute of Health and Welfare for 2018 and 2019 suggests a slight downturn.
The figure above is from AIHW.
Last August I wrote an analysis, available on the website of the US Studies Centre, that looked at the impact of the coronavirus pandemic on substance abuse in both the United States and Australia and government responses to this growing challenge.
In searching for further information to update this (I didn’t really find anything for Australia), I found a recent paper highlighting the success, over 21 years, of the Aboriginal Medical Service Cooperative Redfern in the provision of opioid substitution treatment and counselling. The paper is by Bradley Freeburn (a Bundjalung man who trained as an Aboriginal Health Worker at the AMS and who has been coordinator of the Drug and Alcohol Unit since it was founded), Summer Loggins, Associate Professor Kylie Lee and Professor Kate Conigrave.
The Redfern AMS now cares for 150 people in their opioid substitution treatment program that is integrated and co-located with physical and mental healthcare services.
The paper notes that several other ACCHSs around Australia now provide opioid substitution treatment as part of their drug and alcohol programs and that “this demonstrates the feasibility of accessible, holistic and culturally secure care for substance use disorders within a primary care service”.
The authors also state that this model is worth considering and evaluating in Indigenous and non-Indigenous health services worldwide.
The best of Croakey
Don’t miss this recent news feature by Nicole MacKee: At a time when the pandemic is underscoring the urgent need for primary healthcare reform, what are the opportunities for visionary new models?
The good news story
There’s not much good news here around vaccine distribution, but thanks to New Zealanders and the people of Tokelau for this great story – an example of how planning and team work can get needed coronavirus vaccines to the smallest islands in the remote Pacific.
Tokelau is a dependent territory of New Zealand about 3,500 kilometres north of Auckland with a population of about 1,500. It is one of the most inaccessible atolls in the world. Without an airstrip and with shallow coastal waters, the atolls can only be reached by dinghies, canoes or small rafts.
Also it is one of the few places in the world that has stayed free of the SARS-CoV-2 virus throughout the pandemic. Its borders have been closed since March 2020, which meant that during the vaccine drop off, a contactless delivery had to be observed.
The New Zealand Ministry of Foreign Affairs and Trade, the Ministry of Health, defence forces and the government of Tokelau all worked to find a route and transportation method that would not compromise the cold chain.
Tokelau’s health sector, which is made up of three doctors – one on each atoll – and 36 nurses, had to be trained to administer the vaccines over Zoom, an effort that was nearly impossible given the poor internet connection. But it was done.
One-hundred and twenty vials of Pfizer vaccine, sufficient to give a first vaccination to 720 people, arrived on 19 July after a six-day journey from New Zealand (vaccination is mandatory for all those eligible). There are some great photos of the last part of this trip here.
Next month this will all be repeated to deliver second doses starting on August 10.
Read more from RNZ and The Guardian.
And watch this clip from the NZ Defence Force.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.
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